Post on 27-Mar-2015
transcript
Crew Resource Management
Presentation Prepared for:
Date: 2009
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What is Crew Resource Management
Crew Resource Management (CRM) is an effective us of “all” resources to minimize errors and improve safety and performance.
1 Fatalit
y
10 lost time injuries
1000 No Loss Accidents
10,000 UNSAFE ACTS!
1000 No Loss Accidents
10,000 UNSAFE ACTS!
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Crew Resource Management
Crew Resource Management evolved from what was initially, “Cockpit Resource Management”.
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Crew Resource ManagementA landmark event was United Airlines flight 173, which occurred in 1978. Flight 173 crashed in a wooded area outside of Portland. The problem which occurred involved an indicator light for the landing gear. It indicated that the landing gear was not completely down. The pilot was informed of a low fuel by his crew after he decided to fly around trying to figure out the light. He either disregarded them or misunderstood them and crashed killing 8 passengers and two crew members. Twenty three other people were seriously injured.
Why were so few killed?
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Lack of Crew Resource Management
July 1, 1988, Hackensack, N.J., - Catastrophic collapse of bowstring trusses. The I.C. was scene with portable over shoulder participating in firefighting. Three (3) firefighters killed in initial collapse, two entombed that ran out of air. After 27 calls for help radio goes silent.
October 27, 1997, Washington D.C., - Fire in a corner grocery store. Crews initiated an aggressive interior attack. Crews evacuated after rapid heat build up and floor shift. Engine 14 exits crew can’t find officer. Crew reports their officer missing on two separate occasions to other officers. Dead officer of Engine14 found in basement.
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Crew Resource Management
From 1997 to 2001 –
500 firefighters died in structure fires and fire fighting operations.
Worcester, Mass. Keokuk, Iowa Louisville, Ky. New York City
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Crew Resource Management
Factors that contributed to these and other fire service tragedies are remarkably similar to factors identified by an industry that began adopting CRM as a mantra more than 25 years ago.
The nation’s aviation industry recognized that human error was the prevailing cause in aviation disasters.
The lessons learned by this industry are worth study by the fire service because of common contributing factors to the deaths in both industries.
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Crew Resource Management
CRM exists when all members of the team actively seek to
prevent adverse effects on the current situations.
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Does the Fire Service Promote a Risk Culture?
Managing risk is our business, we do a great job taking care of Mr. & Mrs. Smith’s risk, but how about our own?
Human behavior patterns suggest that the well intentioned, best trained, consistently performing individuals and groups commit errors. (Titanic)
Accidents are not random occurrences – People cause accidents and make errors.
CRM has a proven history in reduction of errors.
Aviations, Military, and Medical.
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Crew Resource Management
Adrenaline and testosterone contribute to more injuries than structural failure. A key factor in firefighter injury or death is the risk a firefighter will take and their supervisor’s ability to control it.
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How Does It Work?
Six PrinciplesCommunicationDecision-MakingTask AllocationTeamworkS/ADebrief*
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Communication
Barriers and bias block effective communication
Standard language benefits all Practice “active” listening Divide duties to prevent overload Minimize distractions Establish Inquiry/Advocacy patterns
Clear, Concise Respectful Bishop’s Assertive Statement
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Communication
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Decision Making
Axioms Recognize problems Fight the fire Treat the patient Maintain SA Accept input Make a decision
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Task Allocations Know your limits Know your crew’s
limits Capitalize on
strengths Seek out “experts” “Eat the elephant
one bite at a time”
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Teamwork
Leadership
Followership
Photo by Bob Bartosz, Camden Fire Department
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Situational Awareness
Point where reality and perception collide
Reality always wins Beware of loss factors
Ambiguity Distraction Fixation Overload Complacency Unresolved discrepancy
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Debrief Pre-Brief
Topic Decorum
Facilitate Analyze
Operations Human
Behaviors
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For More Information
http://www.iafc.org/associations/4685/files/CRM%20Manual.pdf (downloadable manual)
Okray and Lubnau, Crew Resource Management for the Fire Service. Penwell Publishing
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Crew Resource Management
The National Fire Fighter Near-Miss Reporting System
4025 Fair Ridge DriveFairfax, Virginia 22033
Tel: 703 537 4848Fax: 703 273 0920
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Crew Resource Management
The project is administered by the International Association of Fire Chiefs (IAFC) in
consultation with the National Fire Fighter Near-Miss Reporting System Task Force. The
project is endorsed by IAFC, International Association of Fire Fighters and the Volunteer & Combination Officers Section of the IAFC.
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